Ethics of age de-escalation in pediatric vaccine trials: Attending to the case of COVID-19.

In the development of new vaccines, many trials use age de-escalation: after establishing safety and efficacy in adult populations, progressively younger cohorts are enrolled and studied. Age de-escalation promotes many values. The responsibility to protect children from potential risks of experimental vaccines is significant, not only given increased risks of adverse effects but also because parents and medical professionals have a moral responsibility to protect children from harms associated with novel, uncertain interventions. Further, given that young children cannot provide informed consent, acceptable risks for research requiring proxy consent are lower than for adults making decisions for themselves. Although age de-escalation approaches are widely used in vaccine trials, including notably in the recent development of pediatric COVID-19 vaccines, ethicists have not addressed the benefits and risks of these approaches. Their benefits are largely assumed and unstated, while their potential risks are usually overlooked. There are no official ethics guidelines for the use of age de-escalation in clinical research. In this paper, we provide a systematic account of key moral factors to consider when employing age de-escalation. Analyzing pediatric COVID-19 vaccine development as our key case study, we clarify the benefits, risks, and trade-offs involved in age de-escalation approaches and call for the development of evidence-based best practice guidelines to identify when age de-escalation is likely to be an ethical strategy in vaccine development.

The relational calibration of fear.

In this article, I consider how fear in contexts of crisis shapes and is shaped by agents' relationships. I survey a number of approaches to understanding fearing at the intersection of empirical psychology and philosophy, highlighting the extent to which interpersonal relationships are positioned as involved in processes of fearing, and establish what I take to insufficient attention paid by these approaches to the ways interpersonal relations shape the emotions we come to have. Contexts of acute crisis and uncertainty can involve rapidly adjusting practices of fearing in response to other agents, both those we trust and those we do not. I call for the development of a model of 'relational calibration' for understanding the complex interpersonal dynamics of fearing during crises, including in the context of the COVID-19 pandemic.

Inducing Fear.

This paper offers an ethical consideration of how fear can be a tool of agents, used to deliberately shift people away from existing beliefs, commitments, or habits, or towards new ones. It contends that properly understanding the ethical dimensions of such uses of fear depends in part on a clear understanding of the dynamics of disorientation that can be involved in such uses. Section two begins with a clarification of the connections between fear, orientation, and disorientation. It suggests that experiences of fear are in some cases either orienting or disorienting, and that the disorienting aspects of fear are in need of more attention. Section three shows how experiences of fear can be tools-they can be cultivated and wielded by agents deliberately for multiple reasons, including sometimes in order to disorient or re-orient others. Section four turns to a moral evaluation of these uses of fear, attending specifically to why the dynamics of disorientation and orientation often involved in experiences of fear are important for understanding the moral status of uses of fear.

Being (in)visible in the clinic: A qualitative study of queer, lesbian, and bisexual women's health care experiences in Eastern Canada.

In this article, we examine the ways in which 18 queer, lesbian, and bisexual (QLB) women in Eastern Canada negotiated their visibility in interactions with primary care providers. QLB women patients used a number of strategies to determine risk and to be visible or invisible to their health care providers. We describe participants' disclosure decisions and strategies, and we argue that being visible and invisible requires work on the part of QLB patients in the context of institutionalized heteronormativity. Conceptualizing (in)visibility as work is required in efforts to account for and improve health care interactions across differences.

Prescribing Posttraumatic Growth.

This article introduces questions in psychiatric ethics regarding the substantial field of qualitative and quantitative research into 'posttraumatic growth', which investigates how, after devastating experiences, individuals can come to feel that they have developed warmer relationships, increased spirituality, or a clearer vision of their priorities. In one area of this research, researchers of posttraumatic growth outline strategies for clinicians interested in assisting their patients in achieving such growth. In this article, I articulate two ethical concerns about this account of posttraumatic growth and the practice of growth-oriented therapy. The first is a concern about the status and effects of the ideal of posttraumatic health implicit in their account, and the second a concern about the ethical implications of the clinical recommendations for the post-trauma patient. I argue for the need for more attention to the hazardous implications of relating to patients as though they are on their way to, and themselves largely in control of, their own posttraumatic growth.

Discomfort, judgment, and health care for queers.

This paper draws on findings from qualitative interviews with queer and trans patients and with physicians providing care to queer and trans patients in Halifax, Nova Scotia, Canada, to explore how routine practices of health care can perpetuate or challenge the marginalization of queers. One of the most common "measures" of improved cultural competence in health care practice is self-reported increases in confidence and comfort, though it seems unlikely that an increase in physician comfort levels with queer and trans patients will necessarily mean better health care for queers. More attention to current felt discomfort in patient-provider encounters is required. Policies and practices that avoid discomfort at all costs are not always helpful for care, and experiences of shared discomfort in queer health contexts are not always harmful.